Thinking about Transitioning? Here are the Basics.

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There’s no one way to transition — just like there’s no one way to identify as trans.

What does it mean to transition? Transitioning is the most commonly used term for the process in which someone moves to match their outward gender presentation with their inner reality. This can be a social, medical, or legal process, or some combination of the three. It is a journey that often seems to have a hazy “starting point” and an end point that can feel like a moving target. Familiarizing yourself with your options is a good way to make the process feel less daunting.

Depending on what you decide makes sense for you, transitioning your gender may include surgical procedures, hormone replacement therapy, speech therapy, traditional talk therapy, group therapy, and a variety of other medical and mental health treatments and services — or none at all. However you envision your transition, know that your goals are valid, even though the journey may sometimes feel difficult.

To help you understand some of the questions to ask yourself and your healthcare providers during this process, we’ve put together a guide that explores how the transitioning process might work for some members of the trans community. This isn’t a hard-and-fast how-to manual, but rather a resource to assist you and provide options as you carve your path forward through transition.

Do Your Research

Familiarizing yourself with transgender literature, testimonials, and healthcare data is a great way to figure out where you fit into the big picture. Your transition doesn’t have to resemble everyone else’s, but that doesn’t mean there’s nothing to learn from other transitioning experiences or from trans-friendly doctors and healthcare providers.

A great place to start is the Standards of Care for the Health of Transgender, Transexual, and Gender Nonconforming People. This document, published by the World Professional Association for Transgender Health (WPATH), is a go-to resource for therapists, physicians, and surgeons in helping trans individuals shift from male to female or female to male. While the current seventh version is a major improvement over the sixth — which categorized what we now call gender dysphoria as a disorder — the guide errs on the side of caution when it comes to encouraging medical transitioning. The next version is currently in progress and will include many important updates, including new chapters on non-binary identities and additional guidelines for youths interested in transitioning their gender.

With suggestions for trans-friendly doctors that cover complex topics like depression and gender dysphoria in minors, the Standards of Care are written to prevent trans individuals from regretting their transition — not so much that it happened, but how it happened, at what speed, and with what medical professionals as your guide. When you begin working with a doctor, it’s important to determine whether they’re up to date on the newest version of the Standards of Care and if so, where they stand on its recommendations. Some professionals regard it as a set of strict guidelines that they’re duty bound to follow, while others consider it a loose framework that applies differently to different people. Using Lighthouse’s provider search engine can help you identify doctors with more experience in helping individuals during transition.

As you begin your own transition, it’s also important to seek out other people’s stories and experiences and familiarize yourself with the community as a whole. Transgender Pulse and TG Forum offer extensive online communities where users can connect with other trans folks, while resources like Gender Spectrum’s Gender Stories, the New York Times’ “Transgender Lives” series, and the National Center for Transgender Equality’s blog provide platforms for members of the trans community to share their stories. Transbucket a good resource for surgery photos, and there are also many community run, private Facebook groups where the latest relevant updates and information are shared.

Schedule an Appointment with a Therapist

In the past, trans individuals interested in beginning a physical transitioning had to undergo months — and sometimes years — of counseling before receiving hormone therapy or surgical procedures. Therapists weren’t there to help you understand your options; they were there to act as gatekeepers, determining who was “trans enough” to begin the transitioning process.

Thankfully, this is no longer the model. A new relationship between trans patients and healthcare providers has emerged called “informed consent.” As described in Slate interviews with Dr. Jamison Green, a past president of WPATH, this new model puts trans patients in the driver’s seat. Healthcare professionals should be there to help patients understand the options available, discuss how to resolve gender dysphoria, and assist in understanding side effects or unintended consequences.

Since most health insurance providers won’t cover procedures or complex therapies without a formal diagnosis, however, it’s often still required to see a therapist as a first step in the transition process. As outlined in the new Standards of Care, one or two appointments should be sufficient for insurers if both patient and therapist feel you are emotionally prepared and equipped for transition — and therapists can no longer require you to present as your gender expression for a set amount of time before receiving treatment, a now-defunct rule from the previous Standards of Care.

However, this is a bit of a gray area, as insurance companies and some trans-friendly surgeons often still want to see that someone is in mental health treatment, even though this is not in the WPATH guidelines. Currently, a therapist is supposed to include a statement in their letter that the therapist is “available for coordination of care and welcomes a phone call to establish this” to move the transition process forward. This is interpreted by some to mean that the therapist must have an ongoing relationship with the client as the client moves forward through a medical transition.

If you’re worried about seeing a therapist who isn’t trans-affirming or looking to find the right surgeon for your transition, check out Lighthouse’s network of vetted providers for someone who’s trained to help you start your transition.

Consider the Non-Surgical Transitioning Treatments Available to You

Depending on your ideal transition, several non-surgical options are available. One of the most common is feminizing or masculinizing hormone therapies. Research shows that hormone therapies can be medically necessary for transitioning patients and can improve quality of life.

If you and your psychologist decide that hormone therapy is right for you, you’ll receive a referral to a primary care physician or an endocrinologist that will allow you to start treatment. If you take testosterone (masculinizing hormones), the hormone will eventually stop menstruation, increase muscle mass, begin facial and body hair growth, redistribute fat, and heighten libido. If you take estrogen (feminizing hormones), the treatment will change fat distribution, begin breast formation, reduce typically male pattern hair growth, and decrease androgen production, although additional anti-androgen therapy is often necessary. These therapies are usually taken via intramuscular or subcutaneous injection, though other methods are available including implanted pellets, gels applied to the skin, and pills (for feminizing hormones).

It’s important to remember that these changes are not immediate and often take several years to occur. According to WPATH, most physical changes, whether masculinizing or feminizing, occur over the course of two years with hormones, but certain changes such as facial/body hair growth and body fat redistribution are estimated at two to five years and can take over a decade of consistent hormone therapy to achieve the desired result.

There are occasional complications with pursuing hormone therapies based on preexisting health conditions, so we recommend developing a pre-treatment plan with the doctors involved in your transition to take your current health into consideration. While studies support hormone therapies in inducing virilization through exogenous testosterone, or, alternatively, suppressing androgenic effects through exogenous estrogens (and anti-androgens), side effects related to bone density and cardiovascular issues do occasionally manifest.

You may also be interested in voice therapy to help reach your desired vocal pitch and change socially gendered speech patterns. According to the Grabscheid Voice and Swallowing Center at Mount Sinai Hospital, testosterone treatment will lead to a deeper voice on its own, although some patients may want to work with a medical specialist to help with certain mannerisms. Voice feminization, however, requires more practice. Speech therapy will work to signal a more feminine speaker, but additional surgery may be necessary for those who wish to totally eliminate the lower vocal register.

Finally, going on hormones does affect your ability to reproduce, so if you are interested in fertility preservation, there are a variety of options available, including sperm banking, egg freezing, and embryo freezing. Before starting hormone therapy, discuss the options with a transgender-friendly doctor or endocrinologist to figure out what makes the most sense for you.

Consult with Your Doctor On Surgical Procedures

Many people don’t have either the resources to afford — or the interest in pursuing — surgical operations. That said, if you’re confident surgery is the right step for you and you have the ability to make it happen (financially, physically, logistically, etc), it can be an exciting, nerve-wracking step in your transition.

Before getting into the logistics, it’s important to have a frank conversation with a surgeon about the possible and expected complications from the various forms of surgery, particularly bottom surgery. It is also crucially important to develop an aftercare plan with your surgeon following any kind of surgery. Organizations like the Visiting Nurse Service of New York have specific aftercare programs for transgender health.

Surgical procedures vary based on what your ideal transition looks like. If you want to reduce the size of your Adam’s Apple, a procedure called thyroid cartilage reduction surgery — or a trach shave — will make it less noticeable and can make your vocal pitch more feminine.

Breast implants and face feminization surgery are also available. Estrogens will cause breast growth to a point, but breast implants make it possible to increase the size of the bust more quickly and noticeably. Likewise, estrogen will help facial/body hair to thin to a certain extent, but laser hair removal and other hair treatments like electrolysis are available for full hair removal. Face feminization surgery can reduce the prominence of your chin, change the shape of your nose, alter your hairline, and shift the line of your lips. A trach shave is often included in this procedure as well.

For trans women and gender nonconforming individuals born with a penis, “bottom surgery” usually refers to the surgical options used to remove or alter the penis, scrotum, and testes. To create a vagina and vulva, a doctor will invert penile tissue, reuse scrotal skin, and remove the testes, in a procedure known as a vaginoplasty. This surgery is irreversible, and after a vaginoplasty, a person will need to dilate daily. The dilation schedule can change over time but generally dilation continues throughout one’s life.

Once a vaginoplasty is completed, most people (but not all) are able to have penetrative sex and reach vaginal orgasm. Clitoroplasty — or the creation of a clitoris with existing, sensitive tissue — is often part of the procedure.

Another less common bottom surgery is the orchiectomy, or removal of the testicals and scrotum.

While testosterone will deepen your voice and begin to masculinize your features, face masculinization surgery can amplify traditionally male features. Depending on what you agree on with your provider, this procedure can include the creation of an Adam’s Apple, jaw reshaping, chin contouring, and rhinoplasty. Additionally, the removal of breast or chest tissue — called “top surgery” — can create a more masculine appearance.

For trans men and gender nonconforming individuals with born with a vagina, uterus, and ovaries, bottom surgery calls for several different procedures. A hysterectomy removes the uterus, while a bilateral salpingo-oophorectomy removes the fallopian tubes and ovaries. Phalloplasty, metaoidioplasty, and scrotoplasty use different methods to create penile and scrotal tissue, with testicular implants completing traditionally male genitals to whatever degree makes you comfortable.

Whatever you may be considering when it comes to transitioning, it’s also important to care for the organs you have. A huge issue in the trans community is poor early detection of diseases such as cervical and prostate cancer. If you currently have a cervix, a prostate, or chest/breast tissue, no matter what your gender identity is, it’s important to get them checked by a doctor. It’s crucial to have a doctor who is knowledgeable about these issues and with whom you feel comfortable bringing them up. If you’re in need of a trans-affirming primary care doctor in New York City, check out our provider search engine to find the right doctor for you.

Figuring Out What is Right for You

There are a variety of reasons why some or all of these options may not make sense for you at this time. Your current physical/medical health is a big factor to consider prior to transition and it’s never a simple and straightforward process as there are so many health considerations to keep in mind. Many surgeons will refuse to operate on someone who is not sufficiently medically stable, so transitioning is not a decision that can be made lightly or spur of the moment. Further, if you are a smoker or if your BMI is high enough to be of concern to a doctor or surgeon, a surgeon may refuse to operate as complications from surgery could be extremely harmful. As such, some patients may need to prepare for surgery long before the procedure can be pursued.

Depending on what you decide, cost is always a factor as well. Medical and surgical costs can be prohibitively expensive and often require a leave of absence from work that is not possible for many people.

Many trans people simply don’t want to physically change their bodies or don’t experience the intense discomfort of body dysphoria. Others want some but not all of the effects of transitioning. For example, a transwoman top might struggle with hormones because of erectile dysfunction. A transman might not want facial hair or balding, may not feel comfortable with clitoral growth, or might not be able to tolerate some of the physical side effects such as increased heart disease risk or increased cholesterol.

Some people opt not to take hormones because of worries of potential mood changes. And finally, while there are abundant examples of both safe and tremendously helpful medical transitions, people often cite the lack of long term data as a reason to hold off or refuse medical options.

Consider Altering Your Identity Documents

While not all gender transitions require name changes, some people may want to change their name or legal gender designation in order to complete their social transition. Unfortunately, your ability to do so depends in large part on where you live. Many government agencies — whether at the state or local level — require proof of surgery before changing legal gender designation on official documents like birth certificates, even though you’re generally permitted to change your name. Some states and territories, including Idaho, Ohio, Puerto Rico, and Tennessee, make it extremely difficult, if not outright impossible, to make your transition a legally recognized reality.

However, professional and bureaucratic opinions are evolving. The American Medical Association no longer recommends trans individuals undergo surgical procedures before altering their birth certificates, and some states — like California — have made it easier to legally change your name without proof of surgery.

Embracing the Journey

For most trans folks, transitioning doesn’t have a distinct finish line — a linear process that begins here and ends there. It’s a lifelong journey of aligning your physical appearance and social personhood with your inner reality. It takes time — and it’s important that you transition in a way that’s safe, validating, and supportive.

There’s no requirement that your transition resembles somebody else’s. What matters most is that you move at your own pace, working with healthcare providers who affirm your identity. No matter what your transition may look like, it’s important to seek out emotional support — whether from friends, family, and loved ones or from support networks designed to help you through the process. In New York City alone, there are numerous groups designed to connect the trans community with emotional, financial, medical, and legal transition assistance.

To find a trans or trans-affirming therapist with the knowledge and experience to support your transition — no matter where in the process you are — explore Lighthouse’s vetted network of healthcare professionals.